Bullying and Harassment Report Form

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**If the incident being reported represents an immediate, life-threatening situation, please call 911. **

The Clinton Board of Education is committed to creating and maintaining a safe school climate for all individuals that is free from bullying, teen dating violence, harassment and discrimination. In accordance with state law and the Board’s Safe School Climate Plan, the Board expressly prohibits any form of bullying behavior on school grounds; at a school-sponsored or school-related activity, function or program, whether on or off school grounds; at a school bus stop; on a school bus or other vehicle owned, leased or used by a local or regional board of education; or through the use of an electronic device or an electronic mobile device owned, leased or used by Board of Education.

The Safe School Climate Specialist at each school will investigate and respond to all reports of bullying and harassment. This form may be completed anonymously, however, no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.

Enter your name. Students and parents can choose to submit an anonymous form, but no disciplinary action will be taken against the aggressor solely based on an anonymous report. CPS employees completing this form must provide their names.

Are you a: *

Parent

Student

Staff Member

Administrator

Other:

Required

Please provide your telephone number and/or email address if not filing an anonymous report.

Name the person(s) who is the target of the behavior. *

Name of the school that the person being targeted attends: *

Name of the person this report is filed against: *

Describe the basis for your report. Include details about the incident, participants, background information, and any attempts you have made to resolve the problem. *

Date or dates of incident(s): Date of the incident being reported, or multiple dates for multiple incidents. *

Location or locations of incident(s): Where the bullying or retaliation occurred. This can be one or several locations. *

Please provide the names of any potential witnesses.

Have there been any previous incidents that you are aware of? *

Yes

I don't know

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